Books | Government

April 23, 2007

The Complete Layman's Guide to the Health-Care System

Sarah Arnquist

Elizabeth and Steven Hilsabeck, a young, middle-class couple in Austin, Texas, were excitedly awaiting the arrival of their first children, twins. They had health insurance through Steven's banking job and believed they were prepared for any eventuality. Then their babies were born with severe complications. Baby Parker needed intensive physical therapy if he was ever going to walk, but the Hilsabecks' HMO decided it wasn’t necessary and left them with a bill they couldn't afford. After years of therapy, Parker did eventually learn to walk, but the Hilsabecks lost their home, and their marriage.

"The reason we are having a health-care crisis is that fundamentally you don't make money financing medical care to sick people. To make private insurance work, you are fighting a profit motive so you really have to regulate the hell out of it."

Jonathan Cohn

The Hilsabecks’ tragic tale is one of many that Jonathan Cohn weaves into his narrative about the state of our healthcare system in his new book, Sick: The Untold Story of America's Health Care Crisisand the People Who Pay the Price. Cohn uses their story to explain the origin of HMOs and how politicians once believed them to be a panacea for rising health costs. But he reveals that they only temporarily held down costs, and that they often interfere with patient care.

By most accounts, we've had a "health care crisis" for at least 30 years, and recent polls show most Americans believe the nation's health-care system needs fundamental changes. But most layperson discussions of the state of our health-care system are limited by its mind-boggling complexity.

Sick describes how US policy steps have created the health-care system we know today. Most importantly, though, Cohn, a senior editor at the New Republic, makes these convoluted decisionsand their unintended consequencesaccessible to readers who are interested in understanding America's health-care system, but don't have the time, energy, or scholarship to make sense of the tangle of information.

Cohn found time between cross-country book readings to answer Gelf's questions about what makes Sick different from the shelves of existing health-policy books, what he thinks might happen with health care in the 2008 election, and whether capitalism and good health care are compatible.

Gelf Magazine: Why do we need another book about health policy?

Jonathan Cohn: I got this question a lot when I was selling it to publishers. I felt like there's a huge literature out there on health policy if you're an expert, but there's nothing that simplifies it for average readers. The big problem with the politics of health care is a lot of people don't understand the issues. I wanted to write a book that made health-care policy seem simple and in a way people would grasp it.
Also, I feel like this is an important moment and things are changing.

GM: Why did you decide to write a book that relies on personal narratives to tell the history of the US health-insurance system?

JC: I'm a big believer that unless you've seen it with your own eyes or heard it with your own years, you don't believe it. One of the interesting things about health-care policy is that the statistics can't capture how you can be living a safe middle-class life and then you get a stroke of bad luck that becomes a medical crisis, which then becomes a financial crisis. Then life unravels.
One thing that never occurred to me until I started meeting these people is that when illness strikes, it's going to change your life and overwhelm you. Then add onto that a whole layer of financial concern. These people were working hard and were just simply overwhelmed. There's just so much people can handle. When somebody loses their health insurance, it's like their life is a house of cards and everything comes tumbling down.

GM: How did you decide who to focus on?

JC: I wanted to write a book that really looked at the entire health-care system. I had in my head a map of where I wanted to go. I wanted a story about somebody who worked for a large company and lost their insurance. I wanted to find somebody who was dependent on Medicaid, and someone who depended on retirement benefits.
It was depressingly easy to find stories of people who went through the experiences that I wanted to portray in the book. The hard part was the challenge of finding people who wanted to open up their lives.

GM: Why should a young, healthy, insured professional care about reforming the health-care system?

JC: You're healthy until you're not. People in their 20s get gravely ill. People in their 20s get in car accidents. Part One of my message is that this could happen to you. Part Two is that when it happens this is really bad.
When you're in your 20s, you think you're invulnerable but you're not, and frankly you should pay (for insurance). It's something I think we should all be paying for. I don't care how healthy you are; someday you are going to need medical care. You are paying now so you can have that later.

GM: Your book describes how many companies, including both the original Blue Cross insurance and HMOs, began with mostly pure goals to guarantee insurance by spreading their risk evenly and promoting high quality, efficient health care. But eventually the quest for profits changed their mission. Insurance companies began to weed out the sickest people through selective underwriting. HMOs began restricting care, sometimes even medically necessary care, to conserve costs. Are capitalism and health care incompatible? Can an equitable health-care system that provides a sufficient safety net be built on profit-driven business models?

JC: Capitalism is great for most things, but if you want it to continue working you have to recognize areas where it doesn't work so well and you have to intervene. Health care is one of those areas. The reason we are having a health-care crisis is that fundamentally you don't make money financing medical care to sick people. And you don't make money financing health care to people who are poor.
Employers are the best example. GM was a good employer in the 1950s. GM is dying now because it is still a good employer bound by those contracts to provide benefits (Bloomberg). The model corporation is now Wal-Mart. It can undersell competitors by not offering health insurance to its workers. The result is the CEO of Safeway in California is now advocating for universal health care. Businesses want to get out of providing those benefits.
I guess there is some incompatibility there. How you fix that is open to debate. Some say we should regulate the insurance industry to prevent it from doing things we don't want it to do. They say insurance companies must offer this level of benefits, they can't turn people away because of pre-existing conditions, and they can't raise prices.
Some people say that is hopeless, and that we should replace it with a government-run, single-payer system. I tend to think single-payer health systems are better. I'm not so sure you can't make it work with private insurance. John Edwards, Sen. Ron Wyden, and Gov. Arnold Schwarzenegger have all proposed plans that rely on private insurance.
I try to keep an open mind about it. To make private insurance work, you are fighting a profit motive, so you really have to regulate the hell out of it.

GM: What are some key ideas and messages people should pay attention to while watching the debate develop?

JC: A lot of candidates may say they want universal health insurance, but I want to see some level of specificity. John Edwards has put out a pretty detailed plan. He is opening the debate. So far, Hillary Clinton and Barack Obama have not put out plans.
If people understand how vulnerable they are, they will want this. There's a lot of education that needs to take place and that needs to happen before the next election. I have seen John Edwards doing that. He has shown this is something he cares a lot about. I don't yet know if that's true of the other candidates.

GM: What specifics would you like to see?

JC: The candidates need to convince us that they are serious about this, and specificity is one way to convey seriousness. I'm not sure it takes a point-by-point plan. In fact, from a strategic standpoint, too much specificity can be dangerous. But I think the candidates should at least give us some basic, non-negotiable principlesabout the level of benefits, the broad shape of the system they have in mind, and how they'll pay for it.
Keep in mind that while putting forward a specific plan opens you to more attacks, it also helps you build a mandate. Andif you want to enact universal health care, rather than just win an election on the promiseyou'll need that mandate. The real push back against universal health care will start when it comes time to legislate. And whichever special interests line up against it will fight hard, just like they have in the past. So you need political momentumand you need to build it nowso that you can overcome that resistance.

"I think the candidates should at least give us some basic, non-negotiable principlesabout the level of benefits, the broad shape of the system they have in mind, and how they'll pay for it."

GM: Plans to improve health care in America have come and gone before. Do you think this time will be different?

JC: I think the chances are better than they've been before. I think the situation has gotten demonstrably worse, and it's going to keep getting worse. Also Republicans are doing this, too. Mitt Romney signed a law in Massachusetts. Gov. Arnold Schwarzenegger has a proposal in California. And we also have more business leaders involved.
The political conditions are more favorable to it than in 1994. But it didn't happen in the 1930s and it didn't happen in the 1940s, even though there were positive signs.
There's a lot of work to be done between now and 2009.

Related on the Web: In the New York Times Magazine, Cohn wrote about how the Left and Big Business are teaming up in favor of universal health insurance.